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1301 Gervais Street -Suite 300 /� 1 DUNS NO. 05-397.6551 FED. ID N0. j396090019 `60111 6JIVlr—n
<br />HEDULE
<br />Columbia, South Carolina 29201 � vo FOR SERVICE CALL BRANCH MANAGER ' DOC. EXP.
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<br />SCHEDULED sCRR".RD
<br />SERVICE WEEK TERRITOflY.
<br />2091-545 13011,
<br />!
<br />RALPH TORRES ';
<br />105/31/03
<br />1 �IIC611. CUSTOMER NO. l
<br />03-14- i?1 0023149430
<br />7 0 7 a �'
<br />CODE PREVIOUS BALANCE BAL. VER 60 ArAL.
<br />CREDI'STOCKTON
<br />E 18529,69 1 374ca811
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<br />DIVISION. STOCKTON CA 95236
<br />LOCATION TAX EXEMPTION NO.
<br />C,i 95205
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<br />718 5
<br />SERVICE DATE SALES REP N0. CUSTOMER P.O. NUMBER CUSTOMER PHONE # TAX CODE HANDLING ASSOC. SERVICE TAX C.O.M.S. TAX PRODUCT TAX
<br />COD'' CODE
<br />'-739/ c'AU029 209-948-78 077.,
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<br />SERVICE( A �— REMARKS/ SALES TOTAL WASTE SOLVENT/DRUMS CHANGE CHANGE SERVICE IND. PROMO _ _
<br />DEPT CLAN. CHARGE CC TERM SERVICETERM SCH.DATE CODE N0. r_ � � �;- I �}
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<br />MSDS
<br />GIVEN
<br />PRODUCT 6� { j fl t�„�t' UNIT PRICE TAX CHARGE uoE (WEEKS)(INITIAL) m �n t a
<br />CLEAN sPEN CONIT. SK DOT
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<br />APPROPRIATE
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<br />TOTAL-SERVICE/PRODUCTS ❑
<br />INs 80XES�. LOCAL PHONE NO. STICKER
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<br />USE PP TRANSPORTER 1 ID NO:= USEPA,TF�ANSPORTER;2IQ NO, , ,C�ENERATOR°-US ID NO GENERATOR SATE"ID'I O: - LAMP ASSEMBLY, ❑ ENT SOLVENT
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<br />� ACCEPTANCE CRITERIA -
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<br />11. US DOT DESCRIPTION INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, W. ID.
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<br />12. CONTAINERS
<br />NO.
<br />TYPEg�
<br />13. TOTAL
<br />O NTITY
<br />14. UNIT
<br />Wr/`OL
<br />SK DOT NUMBER
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<br />I CERTIFY THAT MY TOTA
<br />.WASTE STREAMS ARE WITHI
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<br />CCATEGORIES.NE OF THE FOLLOWIN
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<br />0TO220LBS./MONT
<br />LliiiILPA REGULATED) AQLI IJS FARTS WASHER SOLUTION (5*3 GAL)
<br />1ITIALS
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<br />220 LBS. TO 2,200 LBS./MONTH
<br />INITIALS
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<br />GREATER THAN 2,200 LBSJMONTH
<br />2232564,5
<br />INITIALS
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<br />DESIGNATED FACILITY NAME AND ADDRESS SAFETprLEEN
<br />SYSTEMS, 1 CERTIFY THAT NO MATE=RIAL CHANGE HAS OCCURRED U5A EPA ID
<br />INC,1 EITHER IN THE OF THE WASTE
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<br />CHARACTERISTICS
<br />CA MATERIALS OR IN THE.' PROCESS GENERATING THE STATE ID NO.
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<br />5050 r3 L h g Y
<br />WASTE MATERIALS.
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<br />CASH ❑
<br />TOTAL RECEIVED
<br />APPLY PAYMENT TO:,Mr
<br />ANIFEST NO - ,+ I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND
<br />r•'yCONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT.
<br />(.. 2 5— ��.5� PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE
<br />TOTAL CHARGE
<br />(FROM ABOVE)
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<br />> (-
<br />�'
<br />CHECK NUMBER
<br />❑ TODAY'S SERVICE/SALE
<br />WASTE MIN.
<br />(FROM ABOVE)
<br />'.;
<br />'
<br />W 0
<br />®
<br />E] PREVIOUS BALANCE AS FOLLOWS
<br />INDICATED IN THE PAYMENT RECE=IVED SECTION. THE INDIVIDUAL SIGNING THIS
<br />LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS.
<br />®
<br />i� 1� RNs k to c N that the above-named materials are I classiked, packaged, marked and labeled, and are
<br />} ' `. �i E i 9 D a fy property p 9e r
<br />Mope co�aanromm�:percanonaccoa�rotreapplcamereBmanonae+tnaDepartmenterrranapodanen
<br />INVOICE # AMOUNT -- INVOICE #
<br />AMOUNT $
<br />TOTAL DUE
<br />C
<br />PREVIOUS
<br />M
<br />MANIFEST CODE SEQ # yam.
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<br />DO NOT WRITE IN THE AREA BELOW
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<br />CREDIT ,
<br />CARD
<br />� - Print Custo999��ieee Name
<br />CRED(T CARD;NO: t ,AMEX EXPiDATE002314943-3
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<br />CUSTOMER REFERENCE' _
<br />i--------------
<br />Custome s uthorize Representative
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